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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 + PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED '0111 -(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described:This a i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San n Local Health District. r Joaquin Job Address �.+e_> 6 �: v t� _, i Cm` Lot Size ... PM Owner's Name -- PAddress t �J Phone - Contractor `-E W A 1:Tft1NLLAddress11 L A_%ALqLiCense No. 3 Phones()L + TYPE OF WELLYPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR"❑..... " '� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK J .SEWER LINES !, DISPOSAL FLD. PROP. LINE FOUNDATION__,AG RICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELLy�} PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial [I Open Bottom ❑ Manteca Dia. of Well Excavation ; Dia. of Well Casing ❑ Domestic/Private ""t ❑ Gravel Pack ❑ Tracy Type of Casing # S ❑ Public - Specifications d ❑ Other O-Q-Delta- Depth of Grout Seal I Type of Grout E] Irrigation t __Approx. Depth ❑�Eastem Surface Seal Installed by Repair Work Done ❑ Type of Pump a ✓ __q,P. State Work Done Well Destruction F71Well Diameter i Sealing Material hop 5011 � Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic tem p system permitted if public sewer is 00 available within 200 feet./ Installation will serve: Residence Commercial Other }} Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: t—i t Water table depth SEPTIC TANK ❑ Type/MfgC IC Ca act ; p tY No. Compartments U PKG. TREATMENT PLT. ❑ I Method of Disposal ' Dista a to nearest: Well Foundation 1 Property Line 4 I \ LEACHING LINE ❑ No. & Length of..Iines Total leng#h/size 'I FILTER BED ❑ Distance to nearest: Well Foundation ! Property Line SEEPAGE PITS ❑ Depth Size !Number SUMPS i ri ' . ❑ Distance to nearest.—'—Well--4'---Fouiidatiori —! Property Line DISPOSAL?PONDS ❑ # hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not ca y any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature car he faliowin "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws ' California. Th lica st call f all quire ksci� kCmplete drawing on verse - w Signed Title: - -� T �W Date: FOR DEPARTMENT USE ONLY Application Accepte y �^�� Date' re �y f,, Pit or Grout Inspecti y Date Final Inspection by Date 2� ` (0 Additional Comments: --- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71040 ❑ Tracy -885-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 FEE gREMITTEDMOUNT DUE AMOUNT INFO C K RECEIVED BY DATE PERMIT NO. + EH 13-24(REV,1/135) t� EH 14-28